Every finding on record at Dubois Nursing Home

Based on review of clinical records and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for four of seven residents reviewed (Residents 2, 4, 6 and 7). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 15, 2026, revealed that the resident was cognitively intact and was dependent on staff for bathing and showering. The resident's shower schedule indicated that she was to receive a shower every Monday and Thursday on the evening shift. Review of bathing records dated June 2026, and July 2026 revealed no documented evidence that the resident was offered or refused a shower on June 1, 11, or anytime between June 25 and July 13. An annual MDS assessment for Resident 4, dated June 11, 2026, revealed that the resident was cognitively intact, required moderate assistance from staff for personal hygiene, including showers/bathing. The facility's current shower schedule indicated that the resident was to receive showers on Tuesdays and Fridays during the evening shift. However, the residents' bathing records for May, June and July 2026 revealed that staff provided eight showers, instead of the 23 showers she should have received during that time, and there was no documented evidence that the resident was offered and refused showers on any days. Interview with Resident 4 on July 22, 2026, at 12:26 p.m. revealed that the resident gets two showers every week, on Tuesday and Friday in the afternoon. She did file a grievance related to showers and it was resolved. She always reminds staff when it is her shower day. A quarterly MDS assessment for Resident 6, dated May 8, 2026, revealed that the resident was cognitively intact and was dependent on staff for bathing and showering. The resident's shower schedule indicated that she was to receive a shower every Thursday on the evening shift. Review of bathing records dated June 2026, and July 2026 revealed no documented evidence that the resident was offered or refused a shower on June 11 or July 9. There was no documented evidence that a shower was offered on an alternative day. Interview with Resident 6 on July 22, 2026, at 12:10 p.m. revealed that she has not had a shower in a couple of months, however she thought she was to get one every Monday. She gets washed up or a bed bath almost every day, however she would love to get a shower, and it would feel good to have her hair washed. A quarterly MDS assessment for Resident 7, dated May 5, 2026, revealed that the resident was cognitively intact and required assistance from staff for personal hygiene and was dependent for showers/bathing. The facility's current shower schedule indicated that the resident was to receive showers on Tuesdays and during the evening shift. However, the residents' bathing records for May, June and 2026 revealed that staff provided four showers, instead of the eight showers she should have received during that time, and there were two days that the resident was offered and refused showers. Interview with Resident 7 on July 22, 2026, at 12:20 p.m. revealed that the resident was not getting her showers, she washes up every morning and evening. When she asks about a shower they say they will come back and they don't. Interview with the Director of Nursing on July 22, 2026, at 1:55 p.m. confirmed that there was no documented evidence that Residents 2, 4, 6, and 7 received and/or refused showers on the dates mentioned. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to prevent physical and verbal behaviors, and/or failed to develop and implement new interventions to address ongoing physical and verbal behaviors for two of 44 residents reviewed (Residents 8, 68) resulting in psychosocial harm for one resident (Resident 68). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 31, 2026, indicated that the resident was severely cognitively impaired, had verbal behaviors directed at others 1-3 days, and had diagnoses that included dementia. A behavior care plan, most recently revised April 3, 2026, revealed that staff were to identify triggers and what de-escalates behavior; address and anticipate her needs; monitor danger to herself and others; offer stuffed animal when she is agitated; and to use activities to assist with behaviors. An admission MDS assessment for Resident 68, dated January 15, 2026 revealed that the resident was cognitively intact and had no behaviors. A nursing note for Resident 8, dated December 19, 2026 revealed that the resident was holding a stuffed bear and that staff took the bear from her and told her that the bear belonged to everyone, not just her. A nursing note for Resident 8, dated February 28 2026 revealed that she was blocking the walkway to the bathroom in her room preventing her roommate, Resident 68, from getting through. Resident 68 had to ring for assistance to help her get to the bathroom. A nursing note for Resident 8, dated March 14, 2026 revealed that she was arguing with her roommate, Resident 68 and had to be redirected away from her. A psychiatric provider note for Resident 68, dated March 17, 2026 revealed that the resident told the provider that her roommate, Resident 8, hits her and gets into her things. A nursing note for Resident 8, dated March 21, 2026 revealed that she was upset because her roommate, Resident 68 was in her room. A nursing note for Resident 8, dated March 27, 2026 revealed that she attacked her roommate, Resident 68, due to Resident 68 being on her side of the room, which she needed to go through to get to the bathroom. Resident 8 was the aggressor. Resident 8 scratched Resident 68's face and left red marks on Resident 68's face. Resident 8 required anti-anxiety medication to calm her. A nursing note for Resident 68, dated March 27, 2026 revealed that the resident's boyfriend called the facility concerned that the resident was in an altercation with her roommate, Resident 8. A nursing note for Resident 8, dated April 11, 2026 revealed that the resident and her roommate, Resident 68, were shouting at each other and that Resident 8 became very anxious. Resident 8 required an anti-anxiety medication to calm her down. A nursing note for Resident 8, dated April 16, 2026 revealed that Resident 8's psychiatric medications were increased due to her behaviors. A physician's note, dated April 17, 2026 revealed that Resident 8 wheeled herself to the nurse's station and was yelling that she was going to do more than hit the bitch (Resident 68). Resident 8 struck her roommate, Resident 68, with a baby doll and kicked her. Resident 8 was agitated and having vocal outburst. Staff attempted to keep the residents separated, however, Resident 8 continued to swat at staff and attempted to get back to her room and Resident 68. Resident 8 was sent to the hospital and committed involuntarily to the psychiatric unit for her aggression and violent behaviors. A nursing note, dated April 24, 2026 for Resident 8 revealed that she returned to the nursing facility on that date, to the same room she was previously in and with Resident 68 as her roommate. A nursing note for Resident 68, dated April 24, 2026 revealed that she was shaking and stated I'm sorry I'm shaking so bad, I'm just so scared to death with her (Resident 8) being in here and she pointed at Resident 8. According to the facility's census information, undated, Resident 8 and Resident 68 spent April 24, 2026 in the same room and the residents were not placed in separate rooms until April 25, 2026. There was no documented evidence that Resident 8's behaviors toward Resident 68 were assessed to determine if there were any patterns and/or precipitating factors that caused them. There was also no documented evidence that staff monitored the resident's behaviors, and no documented evidence that the interventions on the resident's behavior care plan were revised or that new interventions were developed to address the resident's ongoing behaviors. Further, there was no documented evidence that the residents were separated from the same room until April 25, 2026. Interview with Nurse Aide 2 on April 30, 2026 at 2:25 p.m. revealed that Resident 8 believes everything in the facility is her property and is difficult to redirect. Interview with the Social Services Director, the Assistant Director of Nursing and the Director of Nursing on April 30, 2026 at 2:58 p.m. revealed that Residents 8 and 68 were not separated because the facility was bed locked and there was no where within the locked unit to move them to. They confirmed that documentation revealed that Resident 68 was afraid of Resident 8, that Resident 8 was aggressive and violent to Resident 68, and that they were not separated until April 25, 2026. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non pharmalogical interventions were attempted prior to the administration of a psychotropic medication for one of 44 residents reviewed (Resident 75).Findings include:The facility's policy regarding use pf psychotropic medications, February 27, 2026, indicated that psychotropic medications were used to treat the resident's medical symptoms and maximize the resident's functional potential and well-being while minimizing the hazards associated with psychoactive drug side effects.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 75, dated March 13, 2026, revealed that the resident was cognitively intact, was taking an anti-anxiety medication, and had a diagnosis of anxiety. A care plan, dated March 12. 2026, indicated that staff were to attempt non-pharmalogical interventions such as diversional activities, rest, snacks, etc., prior to administering as needed psychotropics.Physician's orders for Resident 75, dated February 18 and 22, March 1, 9, 20 2026, included orders for the resident to be administered 1 milligram (mg) of lorazepam as needed for anxiety.A review of the medication administration records (MAR) for Resident 75, dated February and March 2026, revealed the resident was administered 1.0 mg of lorazepam on February 20, 22, 24, 26-28, and on March 1-3, 10-15, 18-26, and 28-30, 2026.There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of lorazepam.Interview with the Director of Nursing on April 30, 2026, at 2:52 p.m. confirmed that there were no non-pharmacological interventions attempted prior to the administration of lorazepam for the dates listed above, and there should have been. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 44 residents reviewed (Residents 6, 8, 11) and failed to ensure that laboratory test results for monitoring anticoagulant medications were reported to the physician which resulted in a delay in treatment for one of 44 residents reviewed (Resident 123). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 6, 2026, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, received insulin (medication that lowers blood sugar levels), and had diagnoses that included diabetes. Physician's orders for Resident 6, dated December 10, 2025, included an order for the resident to receive Novolog Solution 100 unit/ml subcutaneously, according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) two times a day (scheduled for 6:30 a.m. and 6:30 p.m.). The sliding scale included giving 0 units of insulin for a blood sugar of 70-200 milligrams/deciliter (mg/dl), 3 units for a blood sugar of 201-250 mg/dl, 4 units for a blood sugar of 251-300 mg/dl, 5 units for a blood sugar 301-350 mg/dl, 6 units for a blood sugar of 351-400 mg/dl, 6 units for a blood sugar of 401-999 mg/dl and to notify the physician for further orders. Resident 6's Medication Administration Record (MAR) for January, February and April 2026, revealed that the residents blood sugar results were between 401-999 mg/dL at 4:30 p.m. on January 7, 20 and 21, February 18 and 25, April 7, 15, 17, 22 and 28, 2026. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were between 401-999 mg/dl on the dates and times mentioned. Interview with the Director of Nursing April 29, 2026, at 3:08 p.m. confirmed that the physician should have been notified when Resident 6's sliding scale results were 401 mg/dL or greater. The facility's medication administration policy, dated February 27, 2026, indicated that medications were to be administered in a safe and timely manner as prescribed by the physician. Physician's orders for Resident 8, dated April 24, 2026, included an order for the resident to receive 12 micrograms/hour Fentanyl patch (a narcotic pain medication), and to change the patch every 72 hours. A nursing note for Resident 8, dated April 24, 2026 at 2:24 p.m. revealed that the dose of the resident's Fentanyl patch was decreased and that a new patch was applied on dayshift that day. A nursing note for Resident 8, dated April 24, 2026 at 5:08 p.m. revealed that the resident was found to have two Fentanyl patches on and that one was removed and destroyed. Interview with the Director of Nursing on April 30, 2026 at 5:39 p.m. revealed that the nurse should have looked for an old Fentanyl patch on Resident 8 prior to placing a new patch on her. Physician's orders for Resident 11, dated September 12, 2025, included an order for the resident to receive Humalog Injection Solution 100 unit/ml subcutaneously, according to a sliding scale three times a day (scheduled for 6:00 a.m., 12:00 p.m., 6:00 p.m.). The sliding scale included giving 0 units of insulin for a blood sugar of 70-150 milligrams/deciliter (mg/dl), 1 unit for a blood sugar of 151-199 mg/dl, 2 units for a blood sugar of 200-249 mg/dL, 3 units for a blood sugar 250-299 mg/dl, 4 units for a blood sugar of 300-349 mg/dl, 5 units for a blood sugar of 350-399 mg/dl, 5 units for a blood sugar 400-600 mg/dl and to notify the physician for further orders. Resident 11's Medication Administration Record (MAR) for March and April 2026 revealed that the residents blood sugar results were between 400-600 mg/dL at 12:00 p.m. on March 20, 22 and 23, 2026; at 6:00 p.m. on March 11, 15 and 18, April 3, 24 and 25, 2026. There was no documented evidence that the physician was notified that the resident's sliding scale blood sugar results were between 400-600 mg/dl on the dates and times mentioned. Interview with the Director of Nursing April 29, 2026, at 3:08 p.m. confirmed that the physician should have been notified when Resident 11's sliding scale results were 400 mg/dL or greater. The facility policy for laboratory tests, dated February 27, 2016, indicated that the physician would be notified immediately if a test was obtained to monitor the blood level of a medication and the level was reported as high (above therapeutic range) or toxic. The nurse would notify the physician promptly and would not give the next dose until the situation had been reviewed with the physician. An admission MDS assessment for Resident 123, dated February 24, 2026, revealed the resident was cognitively impaired, received anticoagulant medication (used to thin blood), and had a diagnosis of heart failure. The resident's care plan, dated March 3, 2026, indicated that he was at risk for bleeding due to anticoagulant therapy, and ordered labs were to be scheduled, results reviewed, and the results reported to the physician. Physician's orders for Resident 123, dated March 12, 2026, included an order for the resident to receive 7.0 mg of Coumadin (medication that thins the blood) at bedtime due to a prosthetic heart valve. The resident was also ordered to have blood drawn for prothrombin time and international normalized ratio (PT/INR - blood tests that determine how long it takes the blood to clot) to monitor the therapeutic levels (appropriate range) of Coumadin to be completed on March 19, 2026. A review of the clinical records for Resident 123, including nursing notes and a laboratory report, dated March 19, 2026, revealed the resident's PT/INR was 16.8/1.45, and there was no documented evidence that the physician was notified of the PT/INR results. A physician's order, dated April 20, 2026, included an order to obtain a PT/INR on April 20, 2026. A laboratory report, dated April 20, 2026, revealed the resident's PT/INR was 16.7/1.44 and physician's orders were received to increase the resident's Coumadin from 7 mg to 10 mg at bedtime, and to recheck the PT/INR on April 22, 2026. Interview with the Director of Nursing on April 30, 2026, at 12:38 p.m. confirmed that the physician was not notified of the results of the PT/INR obtained on March 19, 2026. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush an intravenous (IV) line as ordered by the physician for one of 44 residents reviewed (Resident 134).Findings include:The facility's policy regarding catheter (a tube placed in a vein that can be used to deliver fluids and/or medications) insertion and care, dated February 7, 2026, indicated that midline and central line access devices were to be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication was administered into the venous system. A 10 milliliter (ml) saline flush (a method used to clean a catheter of blood or medication) was to be administered before and after each medication that was infused.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 134, dated March 18, 2026, indicated that the resident was cognitively intact, received an antibiotic, and IV medications.A nursing note, dated March 12,2026, at 4:27 p.m. revealed that the resident was admitted to the facility and had a PICC line to her right upper extremity. Physician's orders, dated March 11 and 12, 2026, included orders for resident's PICC line be flushed with 10 mL of normal saline before and after medication administration, a maintenance flush every shift, and to administer 650 milligrams (mg) of Daptomycin (antibiotic) intravenously for every 24 hours for infection.Resident 134's Medication Administration Record (MAR) for March and April 2026 revealed that the resident received 650 mg of Daptomycin from March 13 to 28, 2026; however, there was no documented evidence that Resident 134's PICC line was flushed every shift as ordered on March 12, 15, 16, 23, 24-29, and 31, 2026, and April 2, 7, 9, 10, 16-18, 23, and 26, 2026. Interview with the Director of Nursing on April 30, 2026, at 2:10 p.m. confirmed that there was no documented evidence that Resident 134's PICC line was flushed every shift as ordered.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 44 residents reviewed (Residents 19, 145).Findings include:The facility's policy regarding medication administration, dated February 27, 2026, indicated that the facility was to administer medications in accordance with written orders, including dosage, frequency, and parameters.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated April 20, 2026, revealed that the resident was moderately cognitively impaired, needed extensive assistance for daily care needs, had a multi-drug resistant organism, and had pressure ulcers.Physician's orders for Resident 19, dated April 21, 2026, included an order for the resident to receive 500 milligrams (mg) of Cefadroxil (an antibiotic) every twelve hours for an infection until May 1, 2026.A review of Resident 19's Medication Administration Record (MAR) for April 2026 revealed no documented evidence that a dose of Cefadroxil was administered on April 22 at 8:00 a.m., April 23 at 8:00 p.m., April 24 at 8:00 a.m. and 8:00 p.m., and April 28, 2026, at 8:00 p.m. Nursing notes, dated April 22 at 7:38 a.m., and April 24, 2026, at 10:45 a.m. and 8:30 p.m. revealed that the Cefadroxil was not available from the pharmacy.An interview with the Director of Nursing on April 30, 2026, at 10:42 a.m. confirmed that there was no documented evidence that Resident 19 received the ordered doses of Cefadroxil on the dates and times mentioned above. Physician's orders for Resident 145, dated April 24, 2026, included orders for the resident to receive 2 grams of Ampicillin intravenously every four hours related to an infected joint prosthesis for six weeks.A review of Resident 19's Medication Administration Record (MAR) for April 2026 revealed no documented evidence that a dose of Ampicillin was administered on April 24 at 9:00 p.m., April 26 at 5:00 a.m., April 27 at 9:00 p.m., April 28 at 5:00 a.m., 5:00 p.m. and 9:00 p.m., and April 29, 2026, at 1:00 a.m. and 5:00 a.m.An interview with the Director of Nursing on April 29, 2026, at 3:27 p.m. confirmed that there was no documented evidence that Resident 145 received the ordered doses of Ampicillin on the dates and times mentioned above.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures. Findings include: The facility's policy regarding meal service, dated February 27, 2026, revealed that food temperatures at point of service to the resident would be monitored according to palatability and maintained according to the guidelines set forth by the Food Safety Guidelines of the Food and Drug Association which state hot foods served to the resident would be palatable served at least 135 degrees Fahrenheit (F) or higher. Interview with Resident 2 on April 27, 2026, at 11:17 a.m. revealed that the food was terrible tasting, cold and he did not like it at all. Interview with Resident 70 on April 27, 2026 at 2:23 p.m. revealed that the resident disliked the food and that it was usually cold. He stated that he does not ask the staff to reheat it because they do not have time. Interview with Resident 84 on April 27, 2026, at 11:45 a.m. revealed that the food was not always warm. Review of the menu for the lunch meal on Wednesday, April 29, 2026, revealed that residents were to receive meatloaf with ketchup glaze, Au gratin potatoes, creamed peas, and chocolate eclairs. Tomato soup was available and served to taste. Observations in the kitchen on April 29, 2026, at 11:54 p.m. revealed that a test tray was placed on the lunch meal cart going to the second floor and parked against the wall until the second cart for the second floor was loaded with meal trays. The cart arrived on the unit at 12:02 p.m., staff passed the meal trays out leaving the doors to the meal cart open the entire time, and the last resident was served and eating at 12:26 p.m. At 12:27 p.m. the temperature of the meatloaf was 126 degrees Fahrenheit (F) and the temperature of the tomato soup was 123 degrees F. The meatloaf was lukewarm and not hot to taste, and the tomato soup was lukewarm, not hot to taste, and tasted sour. Interview with the Dietary Manager on April 29, 2026, at 12:43 p.m. confirmed that the food was to be palatable and was not served at the proper temperature of at least 135 degrees F. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.6(f) Dietary Services. 28 Pa. Code 211.6(b) Dietary Services.

Based on a review of cleaning schedules, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.Findings include:Observations in the kitchen's food prep/ tray line area on April 27, 2026, at 9:38 a.m. revealed that there were three ceiling vents that had an accumulation of dust and rust colored buildup. One ceiling tile was covered with a rust colored buildup.A review of the preventative maintenance schedule for dietary, dated 2026, revealed that there was no documented evidence that the vents or ceiling tile were cleaned or inspected until April 27, 2026.Interview with the Dietary Manager on April 27, 2026, at 9:38 a.m. confirmed that the vents needed cleaned and that maintenance was responsible for cleaning them.28 Pa. Code 211.6(f) Dietary Services.

Based on review of established infection control guidelines and clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 44 residents reviewed (Resident 145).Findings include:CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.The facility's policy regarding EBP, dated February 27, 2026, indicated that EBP's were indicate for residents with wounds and/or indwelling medical devices regardless of MDRO colonization or infection status. Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies.Physician's orders for Resident 145, dated April 24, 2026, included orders for the resident to have a PICC (peripherally inserted central catheter) line and receive two grams of ampicillin intravenously every four hours.Observations of Resident 145 on April 27, 2026, at 10:45 a.m. revealed the resident was in bed and had a PICC line to his right upper arm. There was no evidence that the resident was on Enhanced Barrier Precautions or had PPE in his rom.A review of the clinical record, including physician orders, nurse's notes and current care plans, for Resident 145, revealed that there was no documented evidence that Enhanced Barrier Precautions were ordered.Interview with the Director of Nursing on April 29, 2026, at 1:25 p.m. confirmed that Enhanced Barrier Precautions were not ordered for Resident 145 at the time of admission and should have been.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs for one of 44 residents reviewed (Resident 11) Findings include:The facility's policy for care planning, dated February 27, 2026, indicated that all residents will have an interim, comprehensive, and ongoing plan of care, which will be developed to outline and provide directions and interventions to provide care for the residents. It must be individualized, realistic, functional, and measurable at time frame for completion. Physician's orders for Resident 11, dated September 12, 2025, included an order for the resident to receive Humalog Injection Solution 100 unit/ml subcutaneously, according to a sliding scale three times a day (scheduled for 6:00 a.m., 12:00 p.m., 6:00 p.m.). The sliding scale included giving 0 units of insulin for a blood sugar of 70-150 milligrams/deciliter (mg/dl), 1 unit for a blood sugar of 151-199 mg/dl, 2 units for a blood sugar of 200-249 mg/dL, 3 units for a blood sugar 250-299 mg/dl, 4 units for a blood sugar of 300-349 mg/dl, 5 units for a blood sugar of 350-399 mg/dl, 5 units for a blood sugar 400-600 mg/dl and to notify the physician for further orders. However, there was no documented evidence that Resident 11's care plan included specific and individualized interventions to address care needs for his diabetes. Interview with the Director of Nursing on April 30, 2026, at 12:37 p.m. confirmed that Resident 11's care plan did not include any specific and individualized interventions to address care needs for diabetes.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise residents' care plans for two of 44 residents reviewed (Residents 5, 86). Findings include: The facility's policy for care planning, dated February 27, 2026, indicated that care plans will be reviewed and revised as necessary by the interdisciplinary team at least quarterly or more often as changes occur.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 31, 2026, revealed that the resident was cognitively impaired and required assistance with care needs.Physician's orders for Resident 5, dated March 24, 2026, included an order for the resident to receive 100 mg of Macrobid (an antibiotic) every day for urinary tract infection with the last dose March 31, 2026. A care plan for Resident 5, dated March 30, 2026, indicated that the resident was taking an antibiotic for UTI,There was no documented evidence as of April 30, 2026 that Resident 5's care plan was revised to reflect that the resident was no longer taking an antibiotic.Interview with the Director of Nursing on April 30, at 2:26 p.m. confirmed that Resident 5's care plan was not updated to reflect the resident was no longer taking an antibiotic. An admission MDS assessment for Resident 86, dated January 21, 2026, indicated that the resident was severely cognitively impaired, had behaviors one to three days during the seven day look back period, required assistance from staff for his daily care needs, and had diagnoses that included dementia. A nursing note, dated February 19, 2026 revealed that family wishes Resident 86 to be seated a table (NOT a tray table) for meals, no yellow socks only diabetic socks, no dentures until he sees a dentist and a soft diet until further notice. A nursing note, dated March 9, 2026, revealed that the nurse aide attempted multiple times to wake Resident 86 for morning care and breakfast. Resident very agitated during attempts, was screaming vulgar words at nurse aide and threatening to hit staff. The nurse attempted multiple times to administer medication from 7:30 a.m. to 9:30 a.m., resident told the nurse to get the f*ck out of his room or he would back hand her. There was no documented evidence that Resident 86's care plan was updated to reflect his family's preferences for the resident to be out of bed for all meals, seated at the table for all meals, not to wear yellow socks, and that he should not wear dentures until he is seen by the dentist. Interview with the Director of Nursing on April 30, 2026 at 1:03 p.m. confirmed that Resident 86's care plan should have been updated to reflect his family's preferences regarding his care. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistive devices to prevent accidents for one of 44 residents reviewed (Resident 75). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 75, dated March 13, 2026, revealed that the resident was cognitively intact, used a walker, required extensive assistance from staff for care, had a history of falls, and had diagnoses that included arthritis, muscle weakness, and an abnormal gait and mobility. Physician's orders, dated March 7, 2026, included orders for the resident to transfer with one assist and a front wheeled walker. A care plan, dated April 1, 2026, revealed the resident was at risk for falls and staff were to keep the resident's call bell within reach and encourage her to use it for assistance as needed. A fall investigation, dated April 28, 2026, at 9:25 a.m. revealed the resident was found on the floor in her room after she attempted to self-transfer. She stated that she couldn't sit in her wheelchair any longer and was trying to put herself into her recliner. Observations of Resident 75 on April 30, 2026, at 10:26 a.m. revealed that the resident was in her wheelchair with leg rests on and positioned at the bottom of her bed, and her call bell was lying on the middle of the bed, out of the resident's reach. Interview with Resident 75 at that time revealed that she had been waiting for someone to put her in her recliner chair and she couldn't reach her call bell to ring for help. Interview with Nurse Aide 1 on April 30, 2026, at 10:27 a.m. confirmed that Resident 75's call bell was out of the resident's reach. Interview with the Director of Nursing on April 30, 2026, at 12:38 p.m. confirmed that Resident 75's call bell should have been in the resident's reach. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to change an indwelling urinary catheter as ordered by the physician for one of 44 residents reviewed (Resident 137).Findings include:The facility policy for urinary catheter care, dated February 27, 2026, indicated that changing indwelling catheters or drainage bags at routine, fixed intervals, was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 137, dated February 17, 2026, revealed that the resident was cognitively intact, was dependent on staff for her daily care needs, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition) and a urinary tract infection. Physician's orders for Resident 137, dated February 12, 2026, included an order for the resident to have an indwelling urinary catheter and it was to be changed every month. A care plan, dated February 12, 2026, revealed that the catheter was to be changed as ordered.Treatment Administration Records (TAR's) for March 2026 revealed that Resident 137's urinary catheter was not changed on March 12, 2026, as ordered.Interview with the Director of Nursing on April 30, 2026, at 2:52 p.m. confirmed that there was no documented evidence that Resident 137's urinary catheter was changed during March 2026.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician of laboratory test results for one of 44 residents reviewed (Resident 123).Findings include: The facility policy for laboratory tests, dated February 27, 2016, indicated that the physician would be notified immediately if a test was obtained to monitor the blood level of a medication and the level was reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 123, dated February 24, 2026, revealed the resident was cognitively impaired, received anticoagulant medication (used to thin blood), and had a diagnosis of heart failure. The resident's care plan, dated March 3, 2026, indicated that he was at risk for bleeding due to anticoagulant therapy, and ordered labs were to be scheduled, results reviewed, and the results reported to the physician.Physician's orders for Resident 123, dated March 12, 2026, included an order for the resident to receive 7.0 milligrams (mg) of Coumadin (medication that thins the blood) at bedtime due to a prosthetic heart valve. The resident was also ordered to have blood drawn for prothrombin time and international normalized ratio (PT/INR - blood tests that determine how long it takes the blood to clot) to monitor the therapeutic levels (appropriate range) of Coumadin to be completed on March 19, 2026. A review of the clinical records for Resident 123, including nursing notes and a laboratory report, dated March 19, 2026, revealed no documented evidence that the physician was notified of Resident 123's PT/INR results. Interview with the Director of Nursing on April 30, 2026, at 12:38 p.m. confirmed that the physician was not notified of the results of the PT/INR obtained on March 19, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care for one of seven residents reviewed (Resident 5). Findings include: Review of facility policy for oxygen administration by nasal cannula or mask dated February 27, 2026, indicated that residents who require oxygen will have a physician's order which includes the oxygen flow rate. An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 5 dated January 22, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, had diagnoses that included heart failure, and was receiving supplemental oxygen. Physician's orders for Resident 5 dated February 13, 2024, indicated that the resident was to receive oxygen at three Liters per minute (L/min) via nasal cannula (a lightweight, flexible tube with two small prongs that sits in the nostrils to deliver supplemental oxygen). Observation of Resident 5 on March 3, 2026, at 11:25 a.m. revealed the resident sitting in her wheelchair in her room, with a nasal cannula in place attached to a portable oxygen tank that was empty. Interview with Licensed Practical Nurse 1 on March 3, 2026, at 11:25 a.m. confirmed that Resident 5's portable oxygen tank was empty, and she replaced it with a full one. Observation of Resident 5 on March 3, 2026, at 12:04 p.m. revealed the resident sitting in her wheelchair in the dining room with a nasal cannula in place attached to a portable oxygen tank that had the oxygen flow rate set at 2 L/min. Interview with Licensed Practical Nurse 2 on March 3, 2026, at 12:04 p.m. confirmed that Resident 5's oxygen flow rate was set at 2 L/min and the physician's orders indicated that it should be set at 3 L/min. Interview with the Director of Nursing on March 3, 2026, at 12:56 p.m. confirmed that oxygen should have been administered to Resident 5 according to her physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of seven residents reviewed (Resident 7).Findings include:CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.The facility policy for transmission-based precautions dated February 27, 2026, indicated that transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact precautions staff will wear gloves and disposable gown upon entering the room and remove them before leaving the room.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated February 24, 2026, revealed that the resident was cognitively intact, required assistance for daily care needs, and medical diagnosis that includes urinary tract infection.A physician order for Resident 7, dated February 21 ,2026, included an order for the resident to be on contact isolation for diagnosis of MDRO.Observations on March 3, 2026, at 11:01 a.m. revealed that Nurse Aide 3 was assisting Resident 7 into the bathroom. She did not have a gown per contact isolation policy.Interview with Nurse Aide 3 on March 3, 2026, at 11:01 a.m. confirmed that she did not have an isolation gown on while providing care to Resident 7 and should have.Interview with Licensed Practical Nurse 4 on March 3, 2026, at 11:10 a.m. confirmed that Resident 7 had orders for contact isolation for MDRO.Interview with the Director of Nursing on March 3, 2026, at 12:57 p.m. confirmed that Nurse Aide 3 should have had a gown on when providing care to Resident 7. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of four residents reviewed (Resident 4).Findings include: The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated January 31, 2025, colostomy care will be provided per physician orders to provide the stoma with good skin care and check the condition of the stoma and surrounding skin. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated November 30, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had a diagnosis of sepsis (infection in the bloodstream) and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). A nurse's note for Resident 4, dated November 24, 2025, at 6:47 p.m. indicated that the resident was admitted with a colostomy. A review of Resident 4's clinical record revealed that the ostomy appliance had not been changed or cared for from November 24, 2025, until December 4, 2025, when she was sent out to the hospital. She was readmitted on [DATE], and there was no documentation that the ostomy had been changed or cared for until December 19, 2025. There was no physician's order for changing the ostomy appliance or emptying the colostomy for Resident 4. Interview with the Director of Nursing on February 5, 2026, at 3:44 p.m. confirmed that there was no physician order for the ostomy and that there was no documented evidence that colostomy care was being provided to Resident 4. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as observations staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripherally inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) for one of four residents reviewed (Resident 4). Findings include: A facility policy for the care and maintenance of PICC and midline catheters (a small flexible tube inserted through a vein in your arm that is shorter than a PICC) dated January 31, 2025, indicated that dressing must stay clean, dry and intact. Dressings are to be changed every 5-7 days and as needed when wet, soiled, or not intact. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated November 30, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had a diagnosis of sepsis (infection in the bloodstream) and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). Physician orders for Resident 4 dated November 25, 2025, included orders for PICC line dressing change as needed for slippage or soilage. A review of Resident 4's treatment record for December 2025 revealed that the PICC line was changed on December 14, 2025. There was no documented evidence that the PICC line was changed again until December 24, 2025, 10 days later. Interview with the Director of Nursing on February 5, 2026, confirmed that Resident 4's PICC dressing should have been changed on December 21, 2025, according to the facility's policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 27, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had medical diagnoses that included malignant neoplasm of rectum. Physician's orders for Resident 1 dated December 11, 2025, included orders for the Registered Nurse to disconnect chemotherapy (medications used to treat cancer) pump, flush Medi port (an implanted device under the skin used to provide long term access to a vein for medications), and de-access the port every other Friday. Review of Resident 1's clinical record revealed no documented evidence that a Registered Nurse disconnected his chemotherapy pump, flushed the Medi port and de-accessed the port on December 12, 2025, or on January 16, 2026. Interview with the Director of Nursing on February 5, 2026, at 2:28 p.m. confirmed that there is no documented evidence the registered nurse completed the discontinuation of Resident 1's chemotherapy treatment, flushed Medi port and de-accessed it per physician orders. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of Pennsylvania's Nursing Practice Act, clinical records and staff interviews, it was determined that the facility failed to enter a new resident's physician's orders into the electronic health record which caused the resident to miss two doses of insulin resulting in hospitalization for elevated blood sugars, for one of five residents reviewed (Resident 3). Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.admission paperwork for Resident 3, dated December 19, 2025, indicated that she was a diabetic with diabetic ulcers and that her blood sugar prior to leaving the hospital that day was 182. A nursing note for Resident 3, dated December 19, 2025, indicated that she was admitted from the hospital at 5:30 p.m. and that her physician's orders for medications were reviewed with the provider at 6:06 p.m.Physician's orders, dated December 19, 2025, for Resident 3 included orders for the resident to receive insulin Lispro with sliding scale coverage three times per day with meals; insulin Lispro with sliding scale coverage nightly at bedtime; insulin lispro 7 units daily before breakfast; insulin lispro 3 units two times a day before lunch and supper; insulin Glargine 20 units daily before breakfast; and insulin Glargine 30 units daily before supper.A nursing note for Resident 3, dated December 20, 2025, indicated that the resident was checked at 9:20 a.m. and was still laying on the hospital linens with a soiled disposable pad and brief, and was breathing at 33 breaths per minute (normal is 12 - 20 breaths per minute). The note indicated that the resident did not receive her insulin or medications the night before. Her blood sugar at that time was 503. A repeat blood sugar one hour after medication administration was 530. Her respiratory rate remained fast. At noon her blood sugar was 484 and she was again medicated with insulin. At 1:00 p.m. her blood sugar was 497. The nurse was instructed to send the resident to the hospital because the patient stated she did not feel well.A nursing note dated December 21, 2025 at 1:15 a.m. revealed that the resident was admitted to the hospital with Diabetic Ketoacidosis (DKA - a condition in which the body is lacking insulin and breaks fat down for fuel which produces acidic ketones that build up in the blood causing illness requiring hospitalization), altered mental status, and acute kidney injury, encephalopathy (any illness that changes brain function or structure) and dehydration. A review of Resident 3's December 2025 Medication Administration Record (MAR) revealed that she did not have any orders entered into the electronic health record system for December 19, 2025. A medication entry audit revealed that the orders for Resident 3's medications were entered on December 19, 2025 between 11 p.m. and 12 a.m. and that they were entered to start on December 20, 2025.Hospital emergency room documentation, dated December 20, 2025, revealed that Resident 3 sent to the emergency room with elevated blood sugars, and that she was admitted to the Intensive Care Unit (ICU) with diabetic ketoacidosis and on an insulin drip.Interview with the Director of Nursing on December 29, 2025 at 3:24 p.m. revealed that the Registered Nurse that entered the orders into the computer did not get around to entering them until around midnight on December 19, which pushed the start date of the orders until December 20. She further confirmed that Resident 3 did not receive her supper or bedtime insulin.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 3). Findings include:admission paperwork for Resident 3, dated December 19, 2025, indicated that she was a diabetic with diabetic ulcers and that her blood sugar prior to leaving the hospital that day was 182. A nursing note for Resident 3, dated December 19, 2025, indicated that she was admitted from the hospital at 5:30 p.m. and that her physician's orders for medications were reviewed with the provider at 6:06 p.m.Physician's orders, dated December 19, 2025, for Resident 3 included orders for the resident to receive insulin Lispro with sliding scale coverage three times per day with meals; insulin Lispro with sliding scale coverage nightly at bedtime; insulin lispro 7 units daily before breakfast; insulin lispro 3 units two times a day before lunch and supper; insulin Glargine 20 units daily before breakfast; and insulin Glargine 30 units daily before supper.A nursing note for Resident 3, dated December 20, 2025, indicated that the resident was checked at 9:20 a.m. and was still laying on the hospital linens with a soiled disposable pad and brief, and was breathing at 33 breaths per minute (normal is 12 - 20 breaths per minute). The note indicated that the resident did not receive her insulin or medications the night before. Her blood sugar at that time was 503. A repeat blood sugar one hour after medication administration was 530. Her respiratory rate remained fast. At noon her blood sugar was 484 and she was again medicated with insulin. At 1:00 p.m. her blood sugar was 497. The nurse was instructed to send the resident to the hospital because the patient stated she did not feel well.A nursing note dated December 21, 2025 at 1:15 a.m. revealed that the resident was admitted to the hospital with Diabetic Ketoacidosis (DKA - a condition in which the body is lacking insulin and breaks fat down for fuel which produces acidic ketones that build up in the blood causing illness requiring hospitalization), altered mental status, and acute kidney injury, encephalopathy (any illness that changes brain function or structure) and dehydration. A review of Resident 3's December 2025 Medication Administration Record (MAR) revealed that she did not have any orders entered into the electronic health record system for December 19, 2025. A medication entry audit revealed that the orders for Resident 3's medications were entered on December 19, 2025 between 11 p.m. and 12 a.m. and that they were entered to start on December 20, 2025.Interview with the Director of Nursing on December 29, 2025 at 3:24 p.m. revealed that the Registered Nurse that entered the orders into the computer did not get around to entering them until around midnight on December 19, which pushed the start date of the orders until December 20. She further confirmed that Resident 3 did not receive her supper or bedtime insulin.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records and investigation documents as well as staff interviews, it was determined that the facility failed to implement a care plan for one of five residents reviewed (Resident 2) who was an assist of two for transfers, resulting in a fall with fracture. This deficiency is being cited as past noncompliance. Findings include: An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. A care plan, dated November 15, 2023, revealed that the resident was to be transferred by two staff and a front-wheeled walker. An incident report for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident was yelling to go to the bathroom. Nurse Aide 1 went in to assist the resident and asked Licensed Practical Nurse 2 (who was in the hallway doing her medication pass) how the resident transferred and was told she was an assist of one. Nurse Aide 1 proceeded to assist the resident to the bathroom and transferred her to the toilet. During the transfer from the toilet to her wheelchair, Resident 2 lost her balance and fell . Nurse Aide 1 stated that she tried to steady her but was unable to. A nursing note for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident had a fall in the bathroom. She had complaints of left lower extremity pain. The resident had a left lower extremity deformity and a lump to her left forehead. The physician was notified and ordered the resident to be transferred to the local emergency room . A nursing note for Resident 2, dated March 28, 2024, at 12:42 a.m., revealed that she had a left tibia and fibula (the two bones from the knee to the ankle) fracture that is non-operable and the resident will be returning to the nursing home. A witness statement completed by Nurse Aide 1, dated March 28, 2024, indicated that Resident 2 was yelling that she had to go to the bathroom and her call bell was ringing. She asked Licensed Practical Nurse 2 how the resident transferred because she did not know the resident and was not assigned to her. She asked if she was an assist of one and Licensed Practical Nurse 2 said yes. She stated that she got slipper socks from the resident's drawer and put them on the resident. She transferred the resident into her wheelchair and transferred her to the bathroom. The resident stood and got on the toilet with no issues transferring. She stated that she stayed with Resident 2 until she was finished using the bathroom then stood the resident up with the wheeled walker and cleaned her up. The resident stated she needed to sit down, so Nurse Aide 1 sat her down and rang the call bell for assistance and waited awhile and no one came to assist her. She stated that she checked the hallway and went to the nurse's station for assistance. The resident began yelling that she wanted off the toilet. As she assisted the resident off the toilet her legs began to buckle and the resident fell , and she was unable to stop her. She stated the resident hit her head. She went to get the licensed practical nurse and registered nurse. She was then informed that the resident was to be a transfer assist of two staff members. She stated that she did not have access to the resident's care plan on the iPad and she did not know how to find the transfer status in the charting. A witness statement completed by Licensed Practical Nurse 2, dated March 28, 2024, revealed that she heard the resident yelling out to go to the bathroom and Nurse Aide 1 asked her if she goes to the bathroom. Licensed Practical Nurse 2 indicated that she does use the bathroom because she has helped with toileting her in the past. She then heard Nurse Aide 1 yell that the resident fell . She went with the registered nurse to assist the resident. Licensed Practical Nurse 2 denied telling Nurse Aide 1 that the resident was a one assist for transfers. Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. confirmed that the resident was to be an assist of two staff members and that the transfer status was not followed per Resident 2's care plan. A review of the facility's plan of correction included the following: Reeducation and competencies for transfer status and verifying transfer status in the charting system were completed for all nursing staff, including agency nursing staff. Audits of all agency staff were completed to verify their access to the facility's charting system. A process was added to the orientation program to verify the staff member has access to the facility's charting system. Audits have been conducted on accessing resident transfer status in the charting system. Interviews with nursing staff on April 10, 2024, revealed that they had been educated and were aware of how to locate a resident's transfer status in the charting system. A review of the facility's corrective actions revealed that they were in compliance with F656 on April 2, 2024. Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. revealed that staff education was completed, and ongoing audits will be discussed during the monthly Quality Assurance meeting. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of five residents reviewed (Resident 2), resulting in a fall with fracture. This deficiency was cited as past non-compliance. Findings include: An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. A care plan, dated November 15, 2023, revealed that the resident was to be transferred by two staff and a front-wheeled walker. A nursing note for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident had a fall in the bathroom. She had complaints of left lower extremity pain. The resident had a left lower extremity deformity and a lump to her left forehead. The physician was notified and ordered the resident to be transferred to the local emergency room . A nursing note for Resident 2, dated March 28, 2024, at 12:42 a.m., revealed that she had a left tibia and fibula (the two bones from the knee to the ankle) fracture that is non-operable and the resident will be returning to the nursing home. An incident report for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident was yelling to go to the bathroom. Nurse Aide 1 went in to assist the resident and asked Licensed Practical Nurse 2 (who was in the hallway doing her medication pass) how the resident transferred and was told she was an assist of one. Nurse Aide 1 proceeded to assist the resident to the bathroom and transferred her to the toilet. During the transfer from the toilet to her wheelchair, Resident 2 lost her balance and fell . Nurse Aide 1 stated that she tried to steady her but was unable to. A witness statement completed by Nurse Aide 1, dated March 28, 2024, indicated that Resident 2 was yelling that she had to go to the bathroom and her call bell was ringing. She asked Licensed Practical Nurse 2 how the resident transferred because she did not know the resident and was not assigned to her. She asked if she was an assist of one and Licensed Practical Nurse 2 said yes. She stated that she got slipper socks from the resident's drawer and put them on the resident. She transferred the resident into her wheelchair and transferred her to the bathroom. The resident stood and got on the toilet with no issues transferring. She stated that she stayed with Resident 2 until she was finished using the bathroom then stood the resident up with wheeled walker and cleaned her up. The resident stated she needed to sit down so Nurse Aide 2 sat her down and rang the call bell for assistance and waited awhile and no one came to assist her. She stated that she checked the hallway and went to the nurse's station for assistance. The resident began yelling that she wanted off the toilet. As she assisted the resident off the toilet her legs began to buckle and the resident fell , and she was unable to stop her. She stated the resident hit her head. She went to get the licensed practical nurse and registered nurse. She was then informed that the resident was to be a transfer assist of two staff members. She stated that she did not have access to the resident's care plan on the iPad and she did not know how to find the transfer status in the charting. A witness statement completed by Licensed Practical Nurse 2, dated March 28, 2024, revealed that she heard the resident yelling out to go to the bathroom and Nurse Aide 1 asked her if she goes to the bathroom. Licensed Practical Nurse 2 indicated that she does use the bathroom because she has helped with toileting her in the past. She then heard Nurse Aide 1 yell that the resident fell . She went with the registered nurse to assist the resident. Licensed Practical Nurse 2 denies telling Nurse Aide 1 that the resident was a one assist for transfers. Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. confirmed that the resident was to be an assist of two staff members and that the transfer status was not followed per Resident 2's care plan. A review of the facility's plan of correction included the following: Reeducation and competencies for transfer status and verifying transfer status in the charting system were completed for all nursing staff, including agency nursing staff. Audits of all agency staff were completed to verify their access to the facility's charting system. A process was added to the orientation program to verify the staff member has access to the facility's charting system. Audits have been conducted on accessing resident transfer status in the charting system. Interviews with nursing staff on April 10, 2024, revealed that they had been educated and were aware of how to locate a resident's transfer status in the charting system. A review of the facility's corrective actions revealed that they were in compliance with F689 on April 2, 2024. Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. revealed that staff education was completed, and ongoing audits will be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect caused by staff failing to properly secure a resident in a motor vehicle, which led to a resident sustaining a facial fracture for one of five residents reviewed (Resident 2). This deficiency will be cited as past noncompliance. Findings include: The facility's policy regarding resident abuse and neglect, dated January 1, 2023, indicated that each resident has the right to be free from abuse and neglect. The facility's policy for vehicle safety and management, dated January 1, 2023, indicated that the facility will do everything possible to prevent accidents and is committed to providing a safe environment for all employees and residents. A nursing note for Resident 2, dated December 16, 2023, indicated that the resident was admitted to the facility, was alert to person and place, and had diagnoses that included a fall with rib fractures and end-stage renal disease with dependence on hemodialysis. A nursing note for Resident 2, dated December 18, 2023, revealed that the nursing home administrator was notified the facility bus had been in an accident and that the resident was transferred by Emergency Medical Service to the local emergency room . An incident investigation for Resident 2, dated December 18, 2023, revealed that the transportation aide and resident were in an accident and the resident was transferred to the local emergency room . The driver reports that she secured his wheelchair in the transport van and proceeded to leave the facility to take the resident to the dialysis center for his scheduled appointment. While in route the driver did not see a vehicle that had stopped to make a left-hand turn and the facility transport van rear ended the vehicle that was stopped. As a result of the sudden stop, the force caused the resident to fall forward out of the wheelchair hitting his head on the center console. He was subsequently transferred to the local emergency room where he was also diagnosed with a left mandibular condyle fracture and admitted to the hospital for further observation. A statement from the van driver, dated December 18, 2023, revealed that she brought the resident down to the van but could not push him over the edge because the leg rests would not go over them. She backed him down off the ramp and took the metal attachments off. She then wheeled resident up into the van, locked the wheelchair, put the straps on the back of the wheelchair, went to the passenger side, opened the door, got in and hooked the two straps onto the frame of the wheelchair, made sure they were tight, went back out, put the lap strap around the resident, hooked it on the right side of metal attachment, and made sure the straps were tight. She stated that she did not put the shoulder strap on because she could not figure it out. Everything was tight (the straps), so she got in and put the mileage and time down on a sheet. She then left the nursing home with the resident to transfer him to dialysis. She reached in her pocket when they got to the stop sign on South 8th street to get a cough drop and kept talking to resident. When she got up to top of small hill, she decided to put the cough drop in her mouth. She did not notice the vehicle stopped in front of her. She hit her brakes and hit the vehicle in front of her. She turned off the van and called 9-1-1 at 8:44 a.m. An ambulance was close by. After getting off the phone with 9-1-1, she called the nursing home at 8:46 a.m. She looked back to check on Resident 2 and did not see him. She then noticed he was next to her between the seats. He was bleeding from his right hand and his forehead. She went back to sit with him waiting for the ambulance. She noticed the lap strap was partially under him. Emergency services arrived and assisted the resident and transported him to the local emergency room . Interview with the Nursing Home Administrator on January 11, 2024, at 11:15 a.m. confirmed that the transportation aide did not strap Resident 2 correctly in the facility van and was involved in a vehicle accident that resulted in a fracture of the resident's mandibular. A review of the facility's plan of correction revealed that re-education and competencies were completed by the facility's transportation aides. The facility will perform daily and weekly pre-trip checklists and inspections. Interviews with the facility's transportation aides and Maintenance Director revealed that they received re-education and competencies, and a simulation of transporting a resident safely was conducted. They had knowledge on how to properly secure a resident in the facility's van. A review of the facility's corrective actions revealed that they were in compliance with F600 on December 21, 2023. Interview with the Nursing Home Administrator on January 11, 2024, at 11:15 a.m. revealed that staff education was completed, and ongoing audits are to be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the Pennsylvania Nurse Practice Act and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care, consistent with professional standards, to prevent pressure ulcers, by failing to clarify physician's orders for one of 47 residents reviewed (Resident 87) who was at risk for pressure ulcers, resulting in harm for the resident, who developed two necrotic pressure ulcers that required debridement. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 87, dated October 31, 2020, revealed that the resident was understood, could understand others, required extensive assistance from staff for daily care needs, including hygiene, bathing, transfers and bed mobility, was at risk for the development of pressure ulcers (injuries to the skin and/or underlying tissues, primarily caused by prolonged pressure on the skin), but had no unhealed pressure ulcers and/or other skin conditions at the time of the assessment. The resident's care plan, dated October 26, 2020, and revised on November 6, 2020, revealed that the resident was at risk for impaired skin integrity due to immobility and declining to be repositioned. The care plan included that staff were to assess skin integrity for changes, encourage/assist the resident to reposition every two hours and as needed, reposition the resident every four hours at night, alternate back and left side positioning in bed due to a brace on the right leg, and not position the resident onto his right side due to a brace on the right leg. Physician's orders for Resident 87, dated October 26, 2020, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to complete skin integrity checks to the resident's right lower extremity every shift. There was no documented evidence that staff attempted to clarify the order with the physician, to determine if the hinged brace was to be removed or not in order to complete skin integrity checks. A fracture clinic consultation report for Resident 87, dated December 3, 2020, and completed by a physician, revealed that the resident was at the clinic for follow-up related to a fractured right leg. The physician wrote that it was six weeks since the fracture of the right tibial plateau (a break of the larger lower leg bone below the knee) and now the brace was removed for first time, and evidently there was bilateral (both sides) skin necrosis (death of cells through injury or disease) noted and the resident needed wound care. The hinged brace was to be discontinued and replaced with an immobilizer. The report included that the skin necrosis was secondary to brace pressure. A nursing note for Resident 87, dated December 3, 2020, revealed that the resident returned from a visit to the fracture clinic, who reported that the resident had necrosis secondary to brace pressure. A nursing note dated December 4, 2020, at 7:58 a.m. revealed that the resident's physician was notified regarding the resident's appointment with the fracture clinic and the need for a wound center consultation. A progress note, dated December 4, 2020, at 11:52 a.m. revealed that the right outer knee (upper) had a deep tissue injury (DTI - pressure injury to the tissues underneath intact skin) that measured 4.0 x 2.0 centimeters (cm) with 100 percent dark black eschar (dead tissue); a right outer knee (lower) DTI that measured 4.0 x 1.5 cm with 100 percent dark black eschar; a right inner knee (upper) wound that measured 3.5 x 2.8 cm with 100 percent dark black eschar; and a right inner knee (lower) wound that measured 1.7 x 3.0 cm with 75 percent dark black eschar. No drainage was noted to any of the sites. A wound clinic consultation report for Resident 87, dated December 11, 2020, revealed that the resident presented today due to a new problem of trauma to his right knee. He was treated at the emergency roiagnom on [DATE], for a stress fracture of the tibia, and at that time he was treated with a brace, which subsequently caused pressure ulcers to develop on his knee. The clinic documented the following: Wound 1: an unstageable (the wound bed cannot be visualized) pressure ulcer of the right medial (inside) knee cluster measuring 6.3 x 3.2 x 0.2 (depth) cm with eschar/slough. The wound was debrided (the removal of dead or infected skin tissue) by the physician and post-debridement depth was 0.3 cm. Wound 2: an unstageable pressure ulcer of the right lateral (outside) knee cluster measuring 7.3 x 6.0 x 0.2 cm with eschar/slough. The wound was debrided by the physician and post-debridement depth was 0.8 cm. Interview with the Director of Nursing on August 12, 2021, at 1:20 p.m. revealed that the physician's order did not include whether Resident 87's hinged brace was to be removed or not to complete the skin integrity checks to the resident's right lower extremity. She confirmed that staff should have notified the resident's physician to clarify if the hinged brace was to be removed to perform the skin integrity checks. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies, clinical records and incident investigation documentation, as well as staff interviews, it was determined that the facility failed to implement procedures during toileting and showering to ensure that a resident's safety was not neglected for two of 30 residents reviewed (Residents R4, R14), which resulted in serious injuries for both residents. Findings include: The facility's policies regarding safety alarms and toileting residents, dated January 28, 2016, revealed that any resident who used an alarm was not to be left alone in the bathroom and the staff were to stay with the resident when toileting if the resident was confused or used safety alarms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R14, dated January 19, 2016, revealed that the resident was confused, required extensive assistance with toileting, and had a recent fall. The resident's care plan, dated November 26, 2013 and December 26, 2013, revealed that the resident was at risk for falls and was to use an alarm when in her chair and a tab alarm (an alarm that has a string and clips to the resident's clothing) at all times. The facility's, Fall Investigation Report for Resident R14, dated February 20, 2016, revealed that Licensed Practical Nurse 13 assisted the resident onto the toilet and then walked into the hallway to find another staff member to assist with getting the resident off of the toilet. When Licensed Practical Nurse 13 returned to the bathroom, Resident R14 was observed on the floor. A nursing note for Resident R14, dated February 21, 2016, revealed that the resident's ankle was swollen, had bruising, and the resident had complaints of pain with weight bearing. The physician was notified and orders were received to x-ray the resident's left ankle. An x-ray report, dated February 21, 2016, revealed that Resident R14 had a fractured left ankle. An interview with the Assistant Director of Nursing on September 8, 2016, at 3:26 p.m. confirmed that Resident R14 was left alone on the toilet and should not have been. The facility's policy regarding bathing, dated January 28, 2016, indicated that the staff were to prepare the shower room and equipment, and when the shower was completed, the staff were to assist the resident to dry. An annual MDS assessment for Resident R4, dated July 1, 2016, revealed that the resident required supervision during bathing. The resident's care plan, dated July 5, 2016, indicated that he was to have assistance with bathing and dressing. The facility's, Fall Investigation Report for Resident R4, dated August 19, 2016, revealed that Nurse Aide 8 left the resident unsupervised in a shower chair in order to get a towel, and she came back to find the resident getting up from the shower chair and falling on the slippery floor. A statement by Nurse Aide 8, dated August 19, 2016, revealed that she walked out of the big bathroom to obtain more towels for Resident R4 to dry off, and when she returned she found him on the floor. Nursing notes for Resident R4, dated August 19, 2016, revealed that the resident complained of pain to his left buttocks and when assisting him up off the floor, he was unable to bear any weight to his left leg. The resident was sent out to the emergency room for evaluation and returned after x-rays of the left hip and femur (long bone in the upper leg) were negative. Nursing notes for Resident R4, dated August 20 through August 23, 2016, revealed that the resident continued to experience pain and was unable to bear any weight on his left leg. The resident was sent out of the facility for a CAT scan (a special x-ray test using x-rays and a computer) on August 23, 2016, which revealed multiple pelvic fractures. An interview with the Director of Nursing on September 9, 2016, at 9:51 a.m. revealed that Nurse Aide 8 violated the facility's policy when she left Resident R4 alone in the shower chair. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/22/15, 9/11/14.

Based on review of clinical records and facility policies, as well as staff interviews, it was determined that the facility failed to notify the resident's physician when there was a change in condition for one of 30 residents reviewed (Resident CR5), resulting in a delay in treatment with a deterioration of the resident's medical condition. The facility also failed to follow physician's orders [REDACTED]. Findings include: Admission information for Resident CR5 revealed that the resident was admitted to the facility for rehabilitation on January 28, 2016, following surgery for [REDACTED]. The resident also had [DIAGNOSES REDACTED]. An admission nursing note, dated January 28, 2016, revealed that the incision on the resident's inner right leg was healed. A nursing note for Resident CR5, dated January 30, 2016, at 11:30 a.m. revealed that the healed incision on the resident's right inner leg had a 3.0 centimeter (cm) long area that was slowly breaking open, and there was a scant amount of serosanguinous (yellowish with small amounts of blood) drainage noted. The note indicated that Registered Nurse 14 cleansed the area with wound cleanser and applied a dressing. There was no documented evidence that the resident's physician was notified about this change in the condition of the inner right leg. A nursing note for Resident CR5, dated February 1, 2016, at 10:43 a.m. revealed that a voice message was left for the wound nurse to check the resident's right leg wound. The note indicated that the dressing on the resident's right leg was saturated, so it was replaced with the same type of dressing that was already on it. It was also noted that the resident's inner right leg wound had a big blister under the skin on the left side that was not broken open yet, and the resident complained of pain. There was no documented evidence that the resident's physician was notified about Resident CR5's change in the condition of the right leg wound. A nursing note for Resident CR5, dated February 2, 2016, at 12:32 p.m. revealed that it was a late entry for January 30, 2016. The note indicated that Registered Nurse 15 was notified about an open area to the resident's inner right leg at the end of the incision site. The resident had a 1.0 x 0.5 cm area that appeared to be open at the distal end of the incision site (the end that is away from the center of the body). The area was cleansed with wound cleanser, and a single steri-strip (adhesive skin closure) was applied and covered with a dressing that had one edge of adhesive cut off so that it did not stick to the incision site. There was no documented evidence that the resident's physician was notified about the change in condition of the resident's inner right leg. A nursing note for Resident CR5, dated February 2, 2016, at 5:35 p.m. revealed that the resident presented with the right leg surgical incision dehisced (a surgical wound that has opened up) in two sites at the distal end. The distal end of the incision had a 2.0 x 0.5 cm area that dehisced, and proximal (next to or near) to that was the second dehisced site that measured 1.8 cm x 0.3 cm. The sites were cleansed with wound cleanser and steri strips (adhesive skin closures) were applied. There was also a 2.9 x 7.0 cm fluid filled blister that was partially ruptured to the left side of the incision. There was no documented evidence that the resident's physician was notified about the change in the condition of the right leg wound. A physician assistant's progress note for Resident CR5, dated February 4, 2016, revealed that the resident stated that his leg was killing him and the pain was in the back of his knee and his right lower extremity. The note indicated that the resident had a history of [REDACTED]. A Doppler (a test that uses ultrasound to look at blood flow in the arteries and veins of the legs when a blood clot is suspected) was ordered to be done STAT (immediately). Results of the Doppler, dated February 4, 2016, were positive for a [MEDICAL CONDITION] in the right popliteal (back of the knee) and posterior tibial veins (deep veins in the lower leg). A Physician Assistant's progress note, dated February 4, 2016, revealed that the physician was called and updated, because he had not seen the resident. The physician came in after hours on February 4, 2016, to see Resident CR5 after he was updated on the Doppler results. A physician's history and physical for Resident CR5, dated February 4, 2016, revealed that the resident was being seen for an initial evaluation and that he underwent stenting of the right SFA and was in the facility for rehabilitation. The physician's note indicated that the resident was doing relatively well until last night when he had some ongoing right calf pain that was progressive throughout the night. He was evaluated by the Physician's Assistant at the facility that morning and a Doppler was done which showed an acute right lower extremity [MEDICAL CONDITION]. The physician indicated that he would consult with radiology for the placement of an IVC (inferior vena cava) filter (a device that is inserted to prevent blood clots from traveling to the lungs or heart). A consult with radiology, dated February 5, 2016, revealed that surgery for [REDACTED]. A nursing note, dated February 8, 2016, at 12:55 p.m. revealed that the resident was admitted to the hospital for IVC placement and treatment for [REDACTED]. Interview with the Director of Nursing on September 9, 2016, at 9:43 a.m. confirmed that Resident CR5's physician was not notified about the deteriorating condition of the right extremity incisional wound or his complaints of pain until February 4, 2016, and that he should have been notified immediately. The facility's policy regarding weights, dated January 28, 2016, indicated that weights were to be obtained monthly, or more often as indicated by the resident's condition, the dietary manager, or by physician's orders [REDACTED]. A current [DIAGNOSES REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. Resident R2's weight records for December 15, 2015 through September 4, 2016, revealed that the resident gained 4.4 pounds from December 27 to 28, 2015; 4.4 pounds from December 29 to 30, 2015; 3.6 pounds from January 3 to 4, 2016; 4.4 pounds from January 4 to 5, 2016; 4.2 pounds from January 20 to 21, 2016; 3.1 pounds from February 17 to 18, 2016; 4.2 pounds from February 24 to 25, 2016; 11.4 pounds from March 3 to 4, 2016; 4.2 pounds from March 6 to 7, 2016; 3.2 pounds from March 18 to 19, 2016; 4.6 pounds from May 12 to 13, 2016; 22.3 pounds from May 18 to 19, 2016; 3.5 pounds from June 26 to 27, 2016; 7.0 pounds from July 17 to 18, 2016; 2.2 pounds from July 23 to 24, 2016; 5.3 pounds from August 8 to 9, 2016; 5.2 pounds from August 25 to 26, 2016; and 3.6 pounds from September 2 to 3, 2016. There was no documented evidence that the physician was notified about the resident's weight gains as ordered. In addition, there was no documented evidence that weights were obtained as ordered on July 12, 13, and 25, 2016, and September 5 and 6, 2016. Resident R2's Treatment Administration Records (TAR's) for August and September 2016, revealed that an abdominal girth measurement was not completed as ordered on Fridays, August 26, 2016 and September 2, 2016. Interviews with Registered Nurse 3 on September 7, 2016, at 11:51 a.m. and with the Assistant Director of Nursing on September 8, 2016, at 3:30 p.m. and September 9, 2016, at 2:15 p.m. confirmed that there was no documented evidence that Resident R2's physician was notified about the above weight gains or that weights were obtained daily as ordered. Interview with the Assistant Director of Nursing on September 9, 2016, at 10:50 a.m. confirmed that there was no documented evidence that Resident R2's abdominal girth was measured on the above Fridays as ordered by the physician. The facility's [MEDICAL TREATMENT] service agreement, dated January 14, 2008, indicated that the facility and the [MEDICAL TREATMENT] provider agreed to actively participate in the exchange of information. The facility's policy regarding [MEDICAL TREATMENT], dated, January 28, 2016, indicated that the [MEDICAL TREATMENT] provider was to comment on the [MEDICAL TREATMENT] communication form and return it to the facility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R13, dated August 17, 2016, revealed that the resident received [MEDICAL TREATMENT] services (medical process of removing waste products and excess fluids from the body when the kidneys do not function properly). The resident's care plan, dated May 18, 2016, indicated that the resident was to receive [MEDICAL TREATMENT] services on Tuesdays, Thursdays and Saturdays. [MEDICAL TREATMENT] communication forms for Resident R13 revealed that the facility sent the forms to the [MEDICAL TREATMENT] provider on April 2, 12, 19, 26, 28 and 30, 2016; May 17 and 19, 2016; June 2, 4, 9 and 21, 2016; July 23 and 30, 2016; August 18 and 27, 2016; and September 1, 2016. However, there was no documented evidence that the [MEDICAL TREATMENT] provider sent the forms back to the facility with information about the resident's [MEDICAL TREATMENT] treatments on the above days. Interview with the Director of Nursing on September 9, 2016, at 12:17 p.m. confirmed that [MEDICAL TREATMENT] communication forms used by the facility were to be completed by the [MEDICAL TREATMENT] provider following Resident R13's [MEDICAL TREATMENT] treatments; however, there was no evidence of communication from the [MEDICAL TREATMENT] provider on the above dates. 42 CFR 483.25 Provide Care/services for Highest Well Being. Previously cited 10/22/15, 9/11/14. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/11/14. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/11/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/22/15, 9/11/14.

Based on review of policies and clinical records, as well as staff interviews and observations, it was determined that the facility failed to provide adequate supervision to prevent accidents for two of 30 residents reviewed (Residents R4 and R14), resulting in actual harm for both residents. The facility also failed to provide an environment that was free of accident hazards related to a heated towel warmer on one of three nursing units (fourth floor), and failed to ensure that a resident with a history of bruising had physician-ordered protective devices in place for one of 30 residents reviewed (Resident R6). Findings include: The facility's policies regarding safety alarms and toileting residents, dated January 28, 2016, revealed that any resident who used an alarm was not to be left alone in the bathroom, and the staff were to stay with the resident when toileting if the resident was confused or used safety alarms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R14, dated January 19, 2016, revealed that the resident was confused, required extensive assistance with toileting, and had a recent fall. The resident's care plan, dated November 26, 2013, and December 26, 2013, revealed that the resident was at risk for falls and was to use an alarm when in her chair and a tab alarm (an alarm that has a string and clips to the resident's clothing) at all times. The facility's, Fall Investigation Report for Resident R14, dated February 20, 2016, revealed that Licensed Practical Nurse 13 assisted the resident onto the toilet and then walked into the hallway to find another staff member to assist with getting the resident off the toilet. When Licensed Practical Nurse 13 returned to the bathroom, Resident R14 was observed on the floor. A nursing note for Resident R14, dated February 21, 2016, revealed that the resident's ankle was swollen, had bruising, and the resident had complaints of pain with weight bearing. The physician was notified and orders were received to x-ray the resident's left ankle. An x-ray report, dated February 21, 2016, revealed that Resident R14 had a fractured left ankle. An interview with the Assistant Director of Nursing on September 8, 2016, at 3:26 p.m. confirmed that Resident R14 was left alone on the toilet and should not have been. The facility's policy regarding bathing, dated January 28, 2016, indicated that staff were to prepare the shower room and equipment, and when the shower was completed, staff were to assist the resident to dry. An annual MDS assessment for Resident R4, dated July 1, 2016, revealed that the resident required supervision during bathing. The resident's care plan, dated July 5, 2016, indicated that he was to have assistance with bathing and dressing. The facility's, Fall Investigation Report for Resident R4, dated August 19, 2016, revealed that Nurse Aide 8 left the resident unsupervised in a shower chair in the shower room in order to get a towel, and she came back to find the resident getting up from the shower chair and falling on the slippery floor. A statement by Nurse Aide 8, dated August 19, 2016, revealed that she walked out of the big bathroom to obtain more towels for Resident R4 to dry off, and when she returned she found him on the floor. Nursing notes for Resident R4, dated August 19, 2016, revealed that the resident complained of pain to his left buttocks and when assisting him up off of the floor, he was unable to bear any weight to his left leg. The resident was sent to the emergency room for evaluation and returned after x-rays of the left hip and femur (long bone in the upper leg) were negative. Nursing notes for Resident R4, dated August 20 through August 23, 2016, revealed that the resident continued to experience pain and was unable to bear any weight on his left leg. The resident was sent out for a CAT scan (a special x-ray test using x-rays and a computer) on August 23, 2016, which revealed multiple pelvic fractures. Interview with the Director of Nursing on September 9, 2016, at 9:51 a.m. revealed that Nurse Aide 8 violated the facility's policy when she left Resident R4 alone in the shower chair. The facility's policy regarding, bath-in-a-bag, dated January 28, 2016, revealed that the facility utilized bath-in-a-bag for resident care (a system where wash cloths are soaked with water and a rinse-free bath lotion and placed in plastic bags, which are placed in a towel warmer). Observations on the fourth floor on September 6, 2016, at 2:07 p.m. revealed that the towel warmer in the spa room was set at a temperature of 120 degrees Fahrenheit and contained multiple bath-in-a-bags with moistened wash cloths. The temperature of the wash clothes was 117.3 degrees Fahrenheit. There was no lock on the door to the spa room, and the towel warmer was accessible to residents who entered the spa room. Observations revealed that the door to the spa room was open on September 6, 2016, from 12:30 p.m. through 1:12 p.m., and again at 4:19 p.m.; September 7, 2016, at 11:42 a.m. and 2:10 p.m.; September 8, 2016, at 12:21 p.m.; and September 9, 2016, at 9:43 a.m. There were no staff present in the spa room at these times. Interview with Nurse Aide 1 on September 6, 2016, at 3:17 p.m. revealed that there were approximately six residents who were independently ambulatory or who self-propelled their wheel chairs on the unit. She indicated that the door to the spa room was normally kept closed, but she confirmed that there were no locks on the door to the spa room or on the towel warmer, and there was nothing in place to prevent residents from accessing the towel warmer. An interview with Licensed Practical Nurse 2 on September 6, 2016, at 3:38 p.m. revealed that the facility depended on keeping the door to the spa room closed in order to keep residents from accessing the towel warmer. She confirmed that neither the door to the spa room nor the towel warmer were locked. Interview the Assistant Director of Nursing on September 8, 2016, at 3:30 p.m. confirmed that other than keeping the door to the spa room closed, there was nothing in place to prevent residents from accessing the towel warmer. physician's orders [REDACTED]. A nursing note, dated August 26, 2014, indicated that the resident was to wear Derma Savers to keep her legs from getting bruised when she flailed (wave or swing wildly). Observations on September 7, 2016, at 12:21 p.m. and 1:57 p.m. revealed that Resident R6 was in a comfy chair (specialized chair) and her lower extremities were exposed and did not have Derma Savers on as ordered by the physician. Interview with Licensed Practical Nurse 11 on September 7, 2016, at 1:57 p.m. confirmed that Resident R6 should have had Derma Savers on her legs as ordered by the physician. 42 CFR 483.25(h) Free of Accident Hazards/supervision/devices. Previously cited 10/22/15, 9/11/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/22/15, 9/11/14.